Viral Hepatitis

Pr. Sayeh EZZIKOURI

Module : Microbiology-Immunology

Sub-Module: Virology

Year : 2022-2023

www.um6ss.ma
 Pedagogical Objectives

• To know the main facts and causes of viral

hepatitis (A,B, D, E, & C)
• Describe the characteristics, modes of
transmission, diagnosis, prevention, and
treatment of viral hepatitis
• Describe the challenges of managing
hepatitis B and C
2
 What is hepatitis ?
Hepatitis is an inflammation of the liver. The condition can
be self-limiting or can progress to fibrosis, cirrhosis or liver
cancer

3
 What is viral hepatitis?
• "Hepatitis” means inflammation of the
liver" (CDC, 2015a)
• “The liver is a vital organ that metabolizes
nutrients, filters blood, and fights
infection" (CDC, 2015a)
• Acute viral hepatitis infection means "short-
term illness that occurs within the first six
months (<6 months) of exposure (CDC,
2016a; CDC, 2016b)
• Chronic viral hepatitis infection: "long-term
(>6months) illness that...can last a lifetime
and lead to serious liver problems, including
cirrhosis [and] liver cancer" (CDC, 2016a;
CDC, 2016b)
 Etiology of hepatitis?
Viral Infections

Alcohol

Medicines (drugs)
>1300 Autoimmune diseases
Toxines
Etiology of hepatitis?
 beaucoup d’ampleur, qu’elle apparaît de plus en plus comme une très lourde

Viral hepatitis: A major public health burden

charge pour la santé publique, et enfin que d’immenses possibilités d’agir existent.
Peu de pays les ont exploitées jusqu’à présent : les actions menées ont souvent
été parcellaires et insuffisantes. Le moment est venu de prendre des mesures
de santé publique cohérentes en privilégiant les interventions efficaces, en
encourageant les approches de prestation de services garantissant qualité et

• In 2013, viral hepatitis was the seventh leading cause of

équité, en élargissant la couverture des programmes de manière à obtenir un
impact durable au sein de la population, et en établissant des responsabilités
claires pour les parties prenantes.
death worldwide.
• Causes 1.4 million deaths per year - a figure comparable to
UNE LOURDE CHARGE
POUR LA SANTÉ PUBLIQUE
HIV and tuberculosis La pandémie d’hépatite virale pèse lourdement Sur ce nombre, environ 47 % sont imputable
sur les vies humaines, les populations et les au virus de l’hépatite B, 48 % à celui de

• Approximately 47% are attributable to hepatitis B virus,
systèmes de santé. En 2013, l’hépatite virale était
la septième cause de mortalité dans le monde. Elle
serait responsable de 1,4 million de décès par an
l’hépatite C, et le reste aux virus des hépatite
A et E. L’hépatite virale est également une
cause de mortalité de plus en plus important

48% to hepatitis C virus, and the rest to hepatitis A and E

dus aux infections aiguës ainsi qu’aux cancers du chez les personnes vivant avec le VIH. Envir
foie et aux cirrhoses liés aux hépatites – un chiffre 2,9 millions de personnes vivant avec le VIH
comparable à ceux du VIH et de la tuberculose sont co-infectées par le virus de l’hépatite C

viruses.
(Figure 2). 2,6 millions par le virus de l’hépatite B.5

• Viral hepatitis is an increasingly important cause of death

Figure 2. Estimation du nombre de décès dus à l’hépatite virale, au VIH, au paludisme et à la tuberculose dans l
monde, 2000-2015

among people living with HIV

2,5

2,0
DÉCÈS (EN MILLIONS)

1,5

1,0

0,5 HÉPATITE
VIH
PALUDISME
0,0 TUBERCULOSE
2000 2005 2010 2015
Kouame, Clin Infect Dis 2018. Global Hepatitis Report 2017
 ently, an approach based on direct specific
particles has led to the visualization of
Association between hepatitis B and C and liver
t transmission electron microscopy [22].
nized into a central disc, an irregular ring
n-light crescent potentially corresponding
cancer
he virion (Fig. 1). As recently shown, this
can potentially affect the accessibility of
to neutralizing antibodies [23], indicating
V with lipoproteins contributes to the
glycoproteins from the host immune
e of its lipoprotein components to
HCV attachment factors
CV with lipoproteins has an impact on the
The entry of HCV virion into host cells is
and it has been shown that HCV entry ki-
nsity and thus on the degree of association
the lipids [24].
triglyceride rich lipoproteins, the blood-
e access to hepatocytes after having
al space through fenestrated endothelium.
ons are supposed to bind to negatively
proteoglycans (HSPGs) that are abundant
portantly, virion-associated apoE has been
e initial binding to HSPGs [25,26]. HCV has
ecan-1 or syndecan-4 HSPGs for its initial
he minimal unit required for infection is a
tes the clathrin-dependent endocytosis of
is involved in the first steps of HCV entry.
during infection remains controversial. It
rus attachment to the cell surface through
HBV, ME
HCV, ME
e. HCV particle interacts with lipoproteins and current data suggest the formation of a hybrid particle made of viral and lipoprotein components. The
HCV particle. In this model, the nucleocapsid would be inserted into the hydrophobic lipid core of the lipoprotein due to the hydrophobic nucle-
shows a transmission electron microscopy image of an HCV lipoviroparticle. This image was provided by JC Meunier and E Piver of the University of
see Ref. [22].
Centers for Disease Control and Prevention [CDC], & Cook. N.d.
pathways for HCV and lipoproteins.
3.2. Role of the scavenger receptor B1 (SR-BI) in HCV entry
SR-BI is another lipoprotein receptor that is involved at different
steps of HCV entry. This multi-ligand receptor was first identified as
the major receptor for HDL. It is involved in the selective cholesterol
ester uptake from HDL and the bidirectional transfer of free
cholesterol. SR-BI was recognized as a HCV receptor due to its
interaction with HCV envelope glycoprotein E2 [32]. The precise
process of HCV binding to SR-BI seems to be complex and involves
several steps. Indeed, SR-BI could participate in the initial attach-
ment of the virus to the cell via its interaction with the lipoprotein
components of the particle. In addition, SR-BI mediates a post-
binding event important for viral entry that depends on its lipid
transfer activity and not on the interaction with E2. Finally, SR-BI
could play a last function dependent on E2 glycoprotein hyper-
variable region 1 that leads to enhanced cell entry [33]. Impor-
tantly, the interaction with SR-BI is thought to prime the virions to
interact with the key HCV receptor CD81 which itself interacts with
the tight-junction protein claudin-1 for viral particle internaliza-
tion [34,35].
Until recently, SR-BI and LDLr were thought to participate
independently to HCV entry [29]. But more recently, the use of
novel genome editing techniques allowed generating LDLr and SR-
BI double knockout Huh-7 cells [36]. The characterization of HCV
infection in these cells revealed that SR-BI and LDLr have a
redundant role in HCV entry. Indeed, the impairment of HCV entry
in LDLr/SR-BI knockout cells could be rescued by the exogenous
expression of either SR-BI or LDLr. Whether the redundant use of
SR-BI and LDLr confers an advantage to the virus remains however
to be determined. The ability of these receptors to complement
Huh-7 knockout cells for infection depended on their lipid binding/
uptake activities. In agreement with these findings, HCV pseudo-
typed particles produced in non-hepatic cells were not affected in
their ability to infect LDLr/SR-BI double knockout Huh-7 cells.
Biochimie 141 (2017) 62-69
Viral Hepatitis (A, B, C, D, E)
Hepatitis A virus (HAV)

Kolmioviridae

Hepeviridae

10
 Key facts about hepatitis A
• Hepatitis A is an inflammation of the liver caused by the
hepatitis A virus (HAV) that can range from mild to
severe
• HAV is spread by ingesting contaminated food or
water or by direct contact with an infected person
• Almost all people who contract hepatitis A recover
completely and are immune for the rest of their lives
• A very small proportion of people infected with HAV
may die of fulminant hepatitis
• A safe and effective vaccine is available to prevent
hepatitis A OMS, 27 juillet 2020
 Properties of hepatitis A virus
• Classification: Picornaviridae, Hepatovirus
• Morphology: Non-enveloped, cubic symmetric capsid, and
27 nm in diameter.
• Genome: Single-stranded RNA of positive polarity (7,5 kb)

HEV/EM
 Transmission of HAV
Primarily transmitted through the oro-
fecal route (when an uninfected person
ingests water or food contaminated
with the fecal matter of an infected
person)
 Pathogenicity: Symptoms of hepatitis A (1)
• The incubation period for the hepatitis A virus is
usually 14 to 28 days
- Fever
- Feeling unwell
- Loss of appetite
- Diarrhea
- Nausea
- Abdominal discomfort
- Dark urine and jaundice (yellow coloration of the
skin and the white of the eye)
- Its clinical expression is affected by the age of
the subject:
• In children: inapparent or flu-like forms
• In adults: more frequent icteric forms, with
asthenia
 Pathogenicity: Symptoms of hepatitis A (2)

Age < 6 years 6-14 years 15-39 years < 40 years

Icteric < 10% 40-50% 70-80%

forms

Mortality 0.1% 0.3% 2.1%

Complications :
• Fulminant hepatitis, cholestatic hepatitis
• No risk of cirrhosis or hepatocarcinoma (liver cancer)
 Virological diagnosis of hepatitis A (1)
During the acute phase, liver dysfunction is indicated by elevated
serum bilirubin and transaminases and low prothrombin levels

Diagnosis is based on the detection of IgM HAV antibodies

(persisting 8 to 12 weeks after infection)
Virological diagnosis of hepatitis A (2)
Virological diagnosis of hepatitis A (2)

Ab anti HAV IgM Ab anti HAV IgG Interpretation

- - non-immunized
subject

+ + acute phase,
infectious subject

- + Past Infection,
immune subject
 HAV Prevention

• Compliance with universal hygiene measures is essential

but not sufficient
• Vaccination well tolerated and very effective
Hepatitis E virus (HEV)

Kolmioviridae

Hepeviridae

20
 Key facts about hepatitis E
• Hepatitis E is an inflammation of the liver caused by the
hepatitis E virus (HEV)
• WHO estimates that hepatitis E caused approximately 44,000
deaths in 2015 (3.3% of all viral hepatitis deaths)
• The HEV is transmitted via the fecal-oral route, primarily
through contaminated water
• Hepatitis E occurs worldwide, but is most common in East and
South Asia.
• A vaccine to prevent hepatitis E has been developed and
licensed in China, but is not yet available elsewhere

WHO, July 27, 2020

s. This is a summary of the International Committee on

Properties of the hepatitis E virus

which is available at www.ictv.global/report/hepeviridae.

Classification: Hepeviridae, Orthohepevirus

virus Burma (M73218), species Orthohepevirus A, genus Orthohepevirus

–34 nm diameter with a single capsid protein

Morphology: Non-enveloped, 27-34 nm in diameter

positive-sense monopartite RNA containing three ORFs
on with the host endoplasmic reticulum
RF1) and a subgenomic (ORF2 and ORF3) capped mRNA

Genome: Single-stranded RNA of positive polarity (7,2 kb)

pevirus A, C and D), birds (Orthohepevirus B) and trout (Piscihepevirus)

1. Negative contrast electron micrograph of human hepatitis E

s virions from a case stool collected in Nepal. (A) virion and (B)
ty capsid. The bar represents 100 nm (photograph from M. Purdy).

Human
d Prevention, MS-A33, 1600 Clifton Rd NE, Atlanta, GA 30329,
3
Wellcome Trust/DBT India Alliance, 1110 DLF Tower B, Jasola,
Institute and State University, Blacksburg, VA, USA; 5Division of
ool of Medicine, Tochigi-ken, Japan; 6Wageningen Bioveterinary
hworth Laboratories, University of Edinburgh, Charlotte Auerbach
 HEV transmission (1)
• HEV is transmitted primarily by the fecal-oral route
(when an uninfected person ingests water or food
contaminated with the feces of an infected person)
• Other routes of transmission have been identified, but
appear to be responsible for far fewer clinical cases:
- Ingestion of undercooked meat or meat products
from infected animals (pig liver or other animals) ;
- Transfusion of infected blood products;
- Vertical transmission of the virus from a pregnant
woman to her child
HEV transmission (2)
 Pathogenicity: Symptoms of hepatitis E
Incubation period following exposure to HEV ranges from 2 to 10
weeks, with an average of 5 to 6 weeks.
- Acute phase: variable (Asymptomatic disease to acute liver failure
- Convalescence phase: Cure
PRIMER
- Chronic phase: Rare (immunodeficient subjects)

Incubation Icteric Convalescent in

period hepatitis phase en
ph
HEV RNA and HEV capsid antigen
no
Anti-HEV IgG
Relative levels

Anti-HEV IgM
ac
Alanine aminotransferase levels by
di
re
co
le
0 2 4 6 8 10 12 16 14 18 20 22 24 26 28 30 32
Kumar et al., NATURE
Weeks since infection
ph
REVIEWS, 2017
Nature Reviews | Disease Primers (FI
|
 Extra-hepatic manifestationsOF HEPATOLOGY
Table 2. Extrahepatic manifestations of acute and chronic hepatitis E.
Organ system Clinical syndrome Notes
*
Neurological ! Neuralgic amyotrophy See main text
*
! Guillain-Barré syndrome
*
! Meningoencephalitis
! Mononeuritis multiplex
! Myositis
! Bell’s palsy, vestibular neuritis and
peripheral neuropathy
Renal* ! Membranoproliferative and See main text
membranous glomerulonephritis
! IgA nephropathy
Haematological ! Thrombocytopenia ! Mild thrombocytopenia is common. Occasionally severe
! Monoclonal immunoglobulin ! Reported in 25% of cases of acute HEV in UK study. Significance uncertain
! Cryoglobulinemia ! Occurs mainly in association with renal disease
! Aplastic anaemia ! case reports only
! Haemolytic anaemia ! case reports only
Other ! Acute pancreatitis ! 55 cases worldwide. HEV gt 1 only. The pancreatitis is usually mild
! Arthritis ! Case reports only
! Myocarditis ! Case reports only
! Autoimmune thyroiditis ! Case reports only
*
There is good evidence to support a causal role for HEV and these associated conditions. For the other extrahepatic manifestations, causality remains to be established.
HEV, hepatitis E virus.

European Association for the Study of the Liver. Journal of Hepatology 2018 vol. 68 j 1256–1271
 counts139,150 and had less-pronounced anti-HEV-specific ized by nerve damage a
HEV diagnosis T cell responses97. (inflammation of the b
of the white and grey m
The association
Suspicion of HEV infection Guillain–Barré syndro
control studies from t
and Japan158 that show
Immunocompetent patients Immunocompromised patients tion in 5–11% of patien
this number was sign
Test for anti-HEV IgM Test for anti-HEV IgM controls. In addition, a
6 out of 73 (8%) patien
had evidence of HEV i
Negative Positive Negative Positive Most of the coho
HEV infection in pati
Test for presence of HEV RNA are from Europe in th
In a cohort study con
No recent Recent or active United Kingdom, 5 o
infection infection Negative Positive neuralgic amyotrophy
at the start of their il
No recent Recent or Europe involving >100
infection active infection phy showed that patien
amyotrophy have a di
Analysis of HEV RNA for HEV RNA testing in blood and faeces pared with that of pati
molecular characterization to determine viral clearance or chronic infection
who do not have evi
Figure 5 | Diagnostic algorithm for HEV infection. Identification of anti-hepatitis
Nature Reviews E
| Disease Primers were significantly mor
 JOURNAL
Hepatitis E treatment
OF HEPATOLOGY

Chronic HEV infection

e tested for HEV
iochemical evidence Reduction of immunosuppression

uced liver injury

onic liver disease* No HEV clearance
hy* HEV clearance
ome*

lained acute neurol- 3 -month course of ribavirin

T** monotherapy

al ALT***
T results.
Serum and stool Relapse after
l.
HEV RNA - ve ceasing ribavirin
occasion. ALT, alanine

6 -month course of Non response to

ribavirin monotherapy ribavirin or intolerant

Persistent HEV
replication in the serum
cases of severe or HEV relapse
r failure. (C2)

Pegylated interferon for 3 months in liver-transplant patients

No alternative available therapy in other transplant patients
 Hepatitis E Vaccination
• HEV: vaccine under study (recombinant vaccine using
the capsid antigen)
• A Chinese hepatitis E virus vaccine has been approved
by the U.S. Food and Drug Administration (FDA) to
enter a clinical trial in April 2019
• The vaccine, available under the trade name Hecolin®,
was originally developed by a research team at Xiamen
University Innovax Biotech Co.Ltd.
• Hecolin® has been used in China since 2012, and is the
only vaccine licensed in the world for the prevention of
hepatitis E
29
1965-1967 "Australia antigen"
Hepatitis B virus (HBV)

Kolmioviridae

Hepeviridae

31
Source: Centers for Diseases Control and Prevention, CDC 2010
 Chronic hepatitis B - a global health problem
• 296 million people were living with chronic hepatitis B
• In 2016, 27 million people were aware of their infection
• 4.5 million (16.7%) of those diagnosed were on treatment
• 887,000 deaths (cirrhosis or hepatocellular carcinoma)
Elimination of HBV infection and HBV-related diseases?

susceptible to HBV
Vaccine
Universal precautions
Acute HBV

Antiviral therapy Chronic HBV

Cirrhosis/liver cancer OMS: 9 juillet 2019

Structure of hepatitis B virus
Large S protein
Middle S protein
Small (major) S protein
 a
Additional information appears
Individuals who are incarcerated13 0.3-3.1

HBV replication
in Box 1.

Figure 1. The Hepatitis B Virion and Replication Cycle

Hepatitis B virion (HBV) HBsAg

HBV subviral HBeAg
polymerase HBV surface antigen (HBsAg) particles
HBV envelope antigen (HBeAg)
Envelope
HBV core antigen (HBcAg)
Nucleocapsid Relaxed circular DNA
PERISINUSOIDAL
SPACE
Precore-core protein
enters the secretory
Exocytosis pathway and is secreted
Binding and entry as HBeAg
NTCP via endocytosis
receptor
GOLGI
H E PATO C Y T E
Uncoating Envelopment A P PA R AT U S
HBsAgs assemble
CYTOPLASM with HBsAg as noninfectious
HBV polymerase subviral particles

Relaxed circular DNA

dsDNA
NUCLEUS

ENDOPLASMIC
Recycling RETICULUM
Completion
Nuclear of DNA synthesis
Relaxed circular DNA entry Nucleos(t)ide analogues
ssDNA Inhibit DNA synthesis
by HBV polymerase

Integration into Reverse

host DNA Core assembly transcription
DNA repair
and RNA
packaging
Pregenomic mRNA
L mRNA HBcAg HBsAg
S mRNA Pregenomic
X mRNA RNA HBV Precore-core
cccDNA Precore mRNA polymerase
protein
Transcription
Translation
HBV genotypes
 Course of HBV infection

95% Transient Infection

80% Subclinical
Adults 20% Acute Disease
5% Persistent
0.1% Fulminant
Infection

HBV Cirrhosis
Infections Liver cancer

80-95%
Infants Subclinical/
Inapparent Persistent
Presentation Infection
Acute hepatitis B virus infection with recovery

Typical serological course

Progression to chronic hepatitis B

Typical serological course

 Who should be tested for HBV ?
• Blood and organs donors
• Hemodialysis patients
• Pregnant women
• Infants of HBsAg + mothers
• Behavioural contacts:
– Household and sexual contacts
– HIV+, MSM, IDU
• Individuals from countries where prevalence is
≥2%
• Patients receiving immunosuppressive therapy
• Abnormal ALT of unknown cause
Main diagnostic tools for HBV detection
• HBsAg: is the main marker of chronic HBV infection when
persistent for >6 months
• anti-HBs : is neutralizing, indicating recovery from acute
infection or efficacy of HBV vaccine
• anti-HBc IgM: marker of acute infection
• anti-HBc IgG : is the main marker of contact with HBV
• HBeAg: is a serological marker of active viral replication
and generally indicates high viral load (≥10,000 IU/mL)
• Anti-HBe: mutually exclusive with HBeAg, is the main
marker of the nonreplicative phase of the infection (viral
load <10,000 IU/ml)
• HBV-DNA: indicates active replication of virus, more
accurate than HBeAg especially in cases of escape
mutants. Used mainly for monitoring response to therapy
infection with (A) Single assay with HBsAg seroprevalence above 0.4%, and
Hepatitis
(B) Two assays with B diagnosis
HBsAg seroprevalence below 0.4%

A HBsAg (A1) B HBsAg

HBsAg (A1) + HBsAg (A1) – HBsAg (A1) +

(Reactive) (Non-reactive)
Report positive Report negative
HBsAg (A2)

Compatible with
HBV infection No evidence HBsAg (A1) + HBsAg (A1) +
of HBV infection HBsAg (A2) + HBsAg (A2) -
Proceed to Advise retesting ± Report Report
NAT testing for positive negative
immunization
quantification if ongoing risk of
WHO guidelines on hepatitis B and C testing

of viraemic known exposure ISBN 978-92-4-154998-1

infection © World Health Organization 2017
42
Some rights reserved. This work is
 Quantifying of HBV DNA level

• cccDNA best marker of viral burden

• Serum HBV DNA level

• Realtime PCR:

• accumulation of PCR product

• Fluorescent probes
• Standard curve 50

Threshold Cycle
40

• Sensitive 30

20

• Wide dynamic range: 10-108 ge/ml 10

0
1 2 3 4 5 6

Concentration log 10

43
HBsAg Antigen quantification

• Better measure of cccDNA

• Seems to reflect response to IFN particularly well

• Decline by week 12 predicts good response
• Less value for NUC therapy
Commercial platforms:
(Abbott and Roche) HBsAgQT

LOD of 0.2 ng/ml

dynamic range:
0.05 to 250 IU/ml
dilution

PNAS September 2014

44
 Hepatitis B treatment

• "The only way to know if you

have HBV is to get tested" (CDC,
2016)
• Treatment can prevent most
deaths in people chronically
infected with HBV
 Current treatments: virus suppression and sustained disease control

Nucleos(t)ide analogs (NUCs)

Virus suppression

HBsAg loss rate

Max 10% after 5 years

Decreased inflammation/fibrosis
Decreased progression
Reversal of fibrosis
Decreased progression
Decreased incidence
but not eliminated

Liaw YF et al, N Engl J Med. 2004; Chang et al, Hepatology 2010; Marcellin et al, Lancet 2013;
Hosaka et al, Hepatology 2013; Kim et al, Cancer 2015; Papatheodoridis et al, J Hepatol 2015
High effectiveness of current treatment........
• Example of HIV-HBV co-infection: Meta-analysis of 23
articles, including cohorts and clinical trials, n=516 patients
on tenofovir (TDF)

A small percentage
continue to have
detectable HBV
DNA after
prolonged
treatment.

Price H et al., PLoS One 2013

Three Definitions of HBV Cure Proposed at the AASLD/EASL Workshop -
Consensus

q Complete sterilizing cure - Viral eradication of the host (unlikely

to be achievable).
q Functional cure
² Sustained HBsAg loss with or without anti-HBs seroconversion
² (combined with improved clinical outcomes in a large
proportion of patients not currently achieved by existing
therapies) is an achievable goal.
q Partial cure
q HBsAg is detectable but HBV DNA is persistently undetectable in
serum after a specified duration of treatment.
Lok et al, Hepatitis B Cure: From Discovery to Regulatory Approval; Hepatology / J Hepatol joint publication; 2017
2 schémas: 2 schémas:
- 4 injections: 0 1 2 12 mois
- 4 injections: 0 1 2 12 mois
- 3 injections: 0 1 6 mois
- 3 injections: 0 1 6 mois
Vaccins monovalents VHB
Vaccins bivalents VHA et VHB
Vaccins héxavalents D T Coq Polio Hib
VHB 50
 Occult HBV infection
•HBsAg negative, but HBV DNA is present in blood or liver
•Other markers variably present
•Past infection with good control,
•Low HBV DNA in blood <100 IU/ml
•Mutants with altered HBsAg: “a” determinant or
•Alterations to preS causing impaired HBsAg secretion
“a” determinant of HBsAg

Sensitive HBV DNA assay needed

50
Hepatitis D (Delta) Virus

Kolmioviridae

Hepeviridae

51
 Hepatitis D (Delta) Virus
• HDV is a defective that requires outer envelope of HBsAg
(hepatitis B virus envelope) for replication and
transmission
• Single‑stranded RNA virus
• Can progress to chronic disease
• Incubation period 30 to 150 days
 Hepatitis D - Clinical Features

• Coinfection with HBV

• Severe acute disease
• Low risk of chronic infection

• Superinfection on top of chronic HBV

• Usually develop chronic HDV infection
• High risk of severe chronic liver disease
 Hepatitis D diagnosis

Serology
Hepatitis D antibody (Anti-HDV)
Melecular testing
HDV RNA must be monitored only in reference
virology centers using well-evaluated techniques

54
 Hepatitis C

Harvey J. Alter Michael Houghton Charles Rice

Hepatitis C virus (HCV)

Kolmioviridae

Hepeviridae
 Hepatitis C Virus (HCV) Profile

Family : Flaviviridae
Genus : Hepacivirus
Genome : (+) ssRNA, ~9.6 kb
Species : Hepatitis C virus (7 genotypes)
Disease : Hepatitis C
Prevalence: 71 million chronic cases
Therapy : PEG-IFN-a + RBV (SVR= 50%)
2011 : PEG-IFN-a + RBV + Telaprevir (SVR ≅75%)
2011 : PEG-IFN-a + RBV + Boceprivir (SVR ≅75%)
2013 : PEG-IFN-a + RBV + Simeprevir (SVR≅ 80%)

SVR: sustained virological response= Loss of HCV RNA > 6 months after stopping therapy
Properties of the HCV virion
HCV genotypes
Hepatitis C: Key Facts

• Liver disease caused by the hepatitis C virus (HCV)

• Major cause of liver cancer
• HCV is a parenterally transmitted virus (transmitted through blood)
• An estimated 71 million people are chronically infected with hepatitis
C
• In 2016, approximately 399,000 people died from complications of
hepatitis C
• Currently, there is no effective vaccine for hepatitis C

OMS: 9 juillet 2019

Prevalence of HCV infection worldwide
Over 70 million chronic carriers worldwide
Modes of HCV Transmission
ØPercutaneous
- Transfusions
- Intravenous drug use
- Transplants from infected donors
- Functional medical examinations
- Tattooing, acupuncture, mesotherapy, etc.
- Occupational exposure (shots)
Ø Per-mucosal
- Perinatal (6%, HCV RNA + mothers)
- Sexual ?
High Risk Groups for HCV Infection
• Subjects who received blood or blood products before 1990
• Hemophiliacs, Dialysis patients
• Intravenous drug users
• Transplant recipients
• Health care workers
Hepatitis C Natural History of Infection
Serologic pattern of acute HCV infection with
recovery
Serologic pattern of acute HCV infection with
Progression to Chronic Infection
 Laboratory of HCV Diagnosis
HCV antibody: Generally used to diagnose hepatitis C
infection. Not useful in the acute phase as it takes at
least 4 weeks after infection before antibody appears.
HCV-RNA: Various techniques are available e.g. PCR
and branched DNA. May be used to diagnose HCV
infection in the acute phase. Howerver, its main use is
in monitoring the response to antiviral therapy.
HCV-antigen: An EIA for HCV antigen is available. It is
used in the same capacity as HCV-RNA tests but is
much easier to carry out.
 HCV Viral load Inter assay variation at low RNA
levels (<log 3)
• RealTime PCR:
• LOD 5-15 IU/mL
• Wide dynamic range
• Inter assay variance at <log 3 IU/ml

• Therapeutic monitoring:

Med Microbiol Immunol.

2015; 204(4): 515–525
Utility of viral load in DAA monitoring?
• Baseline levels don’t affect duration of therapy
• Viral kinetics during therapy don’t necessarily predict outcome
• assay specific decision points
Monitoring for relapse, re-infection can be done with cheaper tests
(qualitative assays)
 Genetic variation of HCV
1-5% within host
15-25% within sub-genotype
30-50% between genotypes

E1, E2 p7 NS5A
- Essential for therapeutic workup
- Commercial options
- NS5B sequence

Lowest variation 5’NCR

-Pan-genotypic PCR

Viruses 2015, 7, 5018-5039 Coding region

 HCV drug resistance testing for DAA
• Testing is recommended in patients who have already
experienced therapeutic failure with DAAs
• Genotype specific PCR and Sanger sequencing , online analysis
T54 D168
V36 V55 R155 V170
F43 Y56 Q80 S122 I132 A156 N174

NS3/4A
M28
Q30
L31 P58 Y93

NS5A
A553
G554
S556
N444 G557
C316 A395 C445 G558
S282 V321 N411 Y448 D559
L159 C289 S368 M414 C451 P495 Y561 S565 I585
L326
NS5B
Clinical utility: Lontok et al., 2015
Previous failure of DAA containing regimen
Targetted testing for particular RAVs in patients with specific
genotypes (like Q80K in genotype 1a)
 Current treatments: Hepatitis C is curable
> 95%

75%

IFN: Interféron 55%

riba: Ribavirine
IP: antiprotéases
DAAs: agents à action directe
40%

6% 16%

IFN IFN IFN IFN PEG IP+ IFN PEG DAAs

6 m. 12 m. + riba + riba + riba >
1989 1994 1998 2001-2011 2011-2013 2014
Current treatments: Hepatitis C is curable
lowing successful therapy) of those at ongo- HCV vaccines due to limited culture capacity fied vaccinia vir
Hepatitis C: Screening problem!
ing risk of infection (5). In addition, DAAs
can select for HCV resistance–associated
and risk of reversion to virulence. However,
there is evidence that protective immunity
long-lasting HCV
in healthy volun
infec
curre
185 million infected a ph
(3% world) HCV
injec
risk
expec
of those cessf
unde
inter
of pr
5% are aware diver
of those critic
a suc
95% are NOT treated
A
and globa
5% no response
5% are treated is ne
of those 95% reduced inclu
risk of liver failure, indiv
cancer, and death
treat
(disease progression and
reinfection can still occur) reinf
disea
The global reach of HCV infection. The approximations show that a minority of HCV infected persons are treated. Treatment some
doesn’t prevent reinfection in those at ongoing risk of infection and disease progression continues in a minority of patients treated. cess t
Global control of hepatitis C virus inter
Andrea L. Cox
variants that limit treatment efficacy. Such against HCV exists in people. Spontaneous given before ind
Science 349, 790 (2015);
variants currently ariseDOI: rarely on treatment,
10.1126/science.aad1302 clearance of HCV infection occurs in about would translate i
but can persist for years after ineffective 25% of acutely infected individuals. Although in which to preve
 Solutions: Universal Screening

üUniversal screening for hepatitis C is a necessary step to

achieve HCV elimination by 2030.

üScreening every adult at least once in their lifetime is

necessary to achieve this goal.